Abstract:

The documentation of breastfeeding as a source of HIV infection in babies has come to
represent a public health dilemma in countries with a high prevalence rate of HIV and where
breastfeeding is the standard norm and essential to child survival (DeCock et al. 2000; WHO
2003). UNAIDS estimated that 630,000 infants are HIV infected through their mothers every
year, 280,000 being infected through their mother’s milk (UNAIDS/WHO 2004). The HIV
prevalence in the antenatal population in Tanzania was 9.6% among pregnant women in
2005. Mother-to-child transmission (MTCT) of HIV contributes to about 5% of the HIV
prevalence in Tanzania (Ministry of Health 2005).
This study aimed to generate knowledge on infant feeding and infant feeding counselling to
HIV-positive mothers that can strengthen programmes for prevention of mother-to-child
transmission of HIV (pMTCT) and policy development in Tanzania. More specifically the
study investigated HIV-positive mothers’ experiences connected to choice of and adherence
to the particular infant feeding methods recommended in pMTCT programmes. It also
explored the challenges experienced by nurses as counsellors in pMTCT programmes, and
hence, developed counselling tools to strengthen the knowledge and performance of
counsellors and the adherence to infant feeding choice among HIV-positive mothers.
Finally, the study evaluated the effectiveness of the counselling tools in strengthening the
quality of counselling and the adherence to infant feeding choice among HIV-positive
mothers.
The study used an explorative qualitative research design employing qualitative
triangulation mainly in-depth interview, focus group discussions and participant observation.
The study was composed of a formative research part and an intervention part. The
formative research focused on the customary infant feeding concepts and practices in the
Kilimanjaro region, as well as on mothers’ and counsellors’ experiences with infant feeding
recommendations in pMTCT programmes. The intervention study focused on the
development of culturally-sensitive counselling tools (‘job aids’) to be employed by nursecounsellors
during the counselling of women linked to pMTCT programmes, as well as by
HIV-positive mothers for reference on how to perform safer infant feeding. The formative
research findings contributed to the identification of the key messages to be communicated
and illustrated in relation to infant feeding method. The intervention study also assessed the impact of the developed counselling tools on mothers’ infant feeding knowledge and
practice.
The findings revealed that there is a gap between intensions and infant feeding practices in
the context where the social expectations to breastfeed are high, and where kin and
neighbours are part of the decision-making team surrounding infant feeding. The study
highlighted the tension between the competing concerns of the medical and social risks
involved in the choice of infant feeding methods. The findings pointed to the expectations
from the environment that a mother should breastfeed and not breastfeeding was seen as a
serious failing of motherhood and might be interpreted as a sign of HIV infection. Other
methods were practiced in hidden. Furthermore, the study argues that the feeding methods
recommended might be difficult to adhere to whether a mother chooses exclusive
breastfeeding or exclusive replacement feeding. The nurse-counsellors expressed a lack of
confidence in their own knowledge of HIV and infant feeding, as well as in their own skills
in assessing a woman’s possibilities of adhering to a particular method of feeding. The
nurse-counsellors were found unable to give qualified and relevant advice to HIV-positive
women on how best to feed their infants. They were confused regarding the appropriateness
of the feeding options they were expected to advice HIV-positive women to employ, and
perceived both exclusive breastfeeding and replacement feeding as culturally and socially
unsuitable. However, most counsellors believed that formula feeding was the right way for
an HIV-positive woman to feed her infant.
Furthermore, the nurse-counsellors were in general not comfortable in their newly gained
role as counsellors and felt that it undermined the authority and trust traditionally vested in
nursing as a knowledgeable and caring profession. The study argued that the condition under
which counsellors are expected to provide quality care needs careful consideration, and
indicated an urgent need for pre- and post service training and support structure necessary to
promote professional confidence and skills for nurse-counsellors. The findings showed that
the national and international guidelines on infant feeding conflict with local knowledge and
reality constructions, and it suggested that strategies to increase safer infant feeding practices
among HIV-positive women should be culturally relevant. A complementary set of counselling materials was developed and included brochures on the
three feeding methods that were found to be socially and culturally acceptable, a Question
and Answer Guide for counsellors, and a toolbox for demonstration. The three brochures on
exclusive breastfeeding, formula feeding and cow’s milk feeding describe the steps to safe
infant feeding, illustrated with images based on local ideas and resources. The brochures
serve as reference material during infant feeding counselling in the ongoing pMTCT
programme and as take-home material for the mother. The counselling tools increased the
knowledge about infant feeding among mothers and strengthened certain aspects of infant
feeding counselling compared with the counselling offered in the standard pMTCT
programme. However, some clear limitations and challenges were revealed in the course of
the study. These were particularly linked to limited counselling related to the risks involved
in mixed feeding and counsellors' bias towards formula feeding among HIV-positive
mothers. Further, poor judgement of the ‘acceptability, feasibility, affordability,
sustainability and safety’ criteria (AFASS) of the various feeding methods in the particular
infant feeding situation of each mother, compromised the quality of infant feeding
counselling and hence, complicated the process of choice. The study calls for a critical
assessment of the concept of informed choice which underlies the international infant
feeding guidelines. Moreover, it argues for the need of a multi-dimensional behaviour
change strategy involving both mothers and counsellors and if possible significant others
who influence choice and decision-making processes.
The study discusses practical, research and policy measures and recommends locally
appropriate interventions that facilitate promotion of exclusive breastfeeding to all mothers
in the community and strengthening infant feeding counselling services as part of an attempt
to reduce MTCT and stigma related to HIV and infant feeding methods.